DREAMS FOR DANNY: Surgical Evaluation Scholarship Application

Question Title

* 1. Your contact Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. Both parents/legal guardians of the child MUST agree to apply for this scholarship, even if the parents are separated or divorced. The only exceptions to this rule are if: 1) the other parent/legal guardian is deceased; 2) there is no other parent/legal guardian (e.g. single parent adoption); 3) only you have SOLE legal custody of the child. If you have SOLE legal custody of the child, you must upload a copy of the custody order.

The other parent/guardian must complete the short form application at the link below as proof of agreement:

https://www.surveymonkey.com/r/ZHZSGNR

What is your parental/guardian status?

I am the mother and legal guardian

I am the father and legal guardian

I am the legal guardian, but not the mother or the father

I am the parent with SOLE legal guardianship

None of the above

Question Title

* 3. If applicable, please upload a copy of the court order granting you sole legal custody of the child here.

Question Title

* 4. Child's date of birth

Date / Time

Date

Question Title

* 5. Is the child a U.S. citizen or permanent resident?

Yes

Question Title

* 6. How many anti-seizure medications is your child taking at this time?

Question Title

* 7. Is the child currently having infantile spasms?

Yes

Question Title

* 8. What is causing your child's seizures?

Question Title

* 9. Please tell us about your child's epilepsy journey:

Question Title

* 10. What do you hope to gain from this surgical evaluation?

Question Title

* 11. If your child has already had a prior surgical evaluation, please describe it here. Include the name of the hospital, names of the neurologist and neurosurgeon who evaluated your child, whether your child was deemed a candidate for any epilepsy surgery, and if so, which epilepsy surgery was recommended.

Question Title

* 12. Please upload a letter from your child's neurologist or pediatrician which confirms that your child has been diagnosed with drug-resistant epilepsy. If you do not have a letter, you can upload a PDF or jpg (picture) of a hospital discharge summary, an email from your child's neurologist or pediatrician, or any other similar documentation.

Question Title

* 13. The maximum travel scholarship award is $1,000 per family. We ask that you request only what's absolutely necessary for your child to receive a surgical evaluation. Leftover funds will be used to provide another family with a travel scholarship if they meet the criteria.

What is the total amount you are requesting for this evaluation?

$100

$200

$300

$400

$500

$600

$700

$800

$900

$1,000

Question Title

* 14. Please indicate the total amount needed for each allowable travel expenditure below:

Air, bus, or train fare ($)

Gasoline ($)

Lodging ($)

Other transportation ($) (e.g. taxi, airport shuttle)

Question Title

* 15. Is your family experiencing financial hardship? If so, please describe:

Question Title

* 16. Are you able to pay for travel costs up front, and then wait for reimbursement from The Brain Recovery Project after submission of receipts?

Yes

No, I am unable to financially pay for travel costs up front

Question Title

* 17. Will you pursue a surgical evaluation if you are not awarded a travel scholarship under this program? Please explain:

Question Title

* 18. I agree to provide The Brain Recovery Project with feedback after the surgical evaluation.

Yes

Question Title

* 19. I agree that I will not contact peer review board members individually to advocate for approval of my application and understand that doing so will cause disqualification from consideration.

Yes

Question Title

* 20. I agree to provide The Brain Recovery Project with all travel receipts and other expenditures under this program. I understand that failure to do so may result in denial of reimbursement.

Yes

Thank you for completing this application. Your application will be reviewed the first week of the next calendar month. You will be contacted after the 15th of the next calendar month to be advised of whether you have been selected to receive a travel scholarship under this program.

Remember, unless you have sole legal custody of the child, the other parent/guardian must complete the short form questionaire here.

We wish you and your family the best of luck.